Social Anxiety Treatment

How to Overcome Social Anxiety?

The good news first: Treatment for social anxiety disorder is pretty effective.

The bad news? Only one in five people ever receive professional therapy for their condition (Grant et al., 2005).

With 80% of socially anxious people never reaching out for help, you could think that someone’s math is off. But there is nothing wrong with these numbers.

Sadly, social anxiety disorder often leads to a paradox. The reason why affected people crave the help and assistance of a qualified professional also explains why they do not seek it: they fear being judged and negatively evaluated (Mechanic, 2007; Olfson et al., 2000).

This conflict is a major problem when it comes to potential treatment. The abbreviation for social anxiety disorder, SAD, was certainly chosen wisely.

Other reasons why socially anxious people may refrain from reaching out for help are the treatment expenses, long distances to therapeutic facilities, and a lack of professionals specializing in social anxiety disorder (Mechanic, 2007; Olfson et al., 2000).

In this comprehensive guide, we will do four things.

First, we zone in on the different treatment variations that have been proven effective to overcome social anxiety disorder.

Like this, you gain an understanding of the different branches of psychotherapy and how they explain and treat social anxiety disorder. This will allow you to identify the treatments you are most inclined to and how they can help you reduce your social fears.

After that, we will have a look at the various medications for social anxiety disorder, focusing on their effects on the brain and body and point out how effective they are.

Next, we will provide you with practical tips, cheat sheets, and additional resources, which will help you reduce your social anxiety step-by-step, even without a therapist.

And lastly, we will map out how you can find the right therapist and initiate psychotherapy. We discuss different treatment delivery formats, such as individual and group therapy, as well as in-person and online treatment, with their respective up- and downsides.

Let’s dive into it!

The Silver Bullet for Social Anxiety: Does it Exist?

Social anxiety disorder accounts for the third most common mental health condition in the world today.

However, finding valid, trustworthy and upright information concerning the disorder can be quite challenging.

Many affected people turn online in order to find answers to their questions.

When it comes to overcoming social anxiety, many self-proclaimed gurus declare they have found some kind of secret formula:

• “Overcome social anxiety completely“
• “Beat social anxiety within days“
• “Crush your insecurity and turn into a social beast“
• “Cure your social anxiety in one session“

Promises like these are tempting, especially for people who are suffering and are looking for ways to get better fast.

From an ethical standpoint, claims of this type should be questioned. Even if there were an easy and magic solution, it would still be problematic to promise a suffering individual that you will provide it with certainty.

Let us be frank with you: there is no silver bullet for social anxiety.

Getting better is going to require commitment, effort, time, and courage. The human psyche is far too complex to be significantly changed in an instant through a minor psychological hack.

However, there are various psychotherapies that typically lead to substantial results within only a couple of weeks.

The most commonly known and applied is cognitive behavior therapy, also called CBT. But there is a wide range of additional approaches that have been proven effective.

Let’s have a closer look at them.

Psychotherapy for Social Anxiety Disorder

When social anxiety was officially recognized as a disorder in 1980 (American Psychiatric Association), treatment options were very limited.

The first treatments for social anxiety to be scientifically studied were various pharmaceuticals, such as benzodiazepines and ß-blockers (which we will discuss later in this guide) and cognitive behavior therapy (CBT).

Cognitive Behavioral Therapy

As its name suggests, CBT was the result of combining cognitive and behavioral approaches to psychopathology.

Its main premise is that the way we think and act determines how we feel. By changing our thoughts and our behavior, we can reduce negative emotions, such as anxiety.

People are not disturbed by things, but by the view they take of them.

– Epictetus

Various experts have proposed different cognitive models which explain social anxiety disorder. Let’s have a look at one of the most accepted ones, designed by Clark and Wells (1995).

The cognitive model emphasizes the importance of past negative social experiences, which trigger negative thoughts when similar situations arise.

These thoughts lead to anxiety symptoms and safety behaviors, which intensify self-consciousness.

A person might have been laughed at for making a mistake when reading out loud in class during adolescence. Whenever similar social situations arise, memories and related negative beliefs are triggered.

Possible beliefs in this particular case could be:

• “I will make a fool of myself when reading the meeting outline to my colleagues.”
• “They will notice how nervous I am and make fun of me.”
• “No one will respect me anymore and my boss will think I am incompetent.”

These thoughts are believed to fuel self-consciousness, anxiety symptoms and safety behavior.

In turn, these components are believed to feed of each other, increasing the person’s social anxiety even further.

In the example mentioned in the graphic, the person may excessively practice reading the outline beforehand in an attempt to control her anxiety symptoms, which will likely produce a paradoxical effect, further increasing her arousal.

She might imagine the worst case scenarios before the event and see herself as insecure while presenting the outline, which yet again worsens her anxiety symptoms.

These, in turn, will increase her self-consciousness even further, trapping her in a vicious cycle of social anxiety.

The negative thoughts, the attention focused on internal sensations, as well as the safety behaviors employed by the individual are addressed in CBT treatment.

Additionally, the person is encouraged to seek gradual exposure to the feared situations, which typically leads to large treatment gains.

Like this, the self-reinforcing anxiety loop can be broken.

A large body of evidence supports the effectiveness of CBT treatment for social anxiety disorder (e.g., Heimberg, 2002).

The average duration of cognitive behavior therapy for social anxiety is about 12 sessions. However, this can vary depending on the institution and therapist you contact.

Psychodynamic Therapy

Another well-studied, but often underrated approach is psychodynamic treatment for social anxiety.

Psychodynamic approaches are interested in the underlying, often unconscious emotional conflicts that may cause social anxiety.

These mostly unconscious drives have been described as a “conflict between craving praise and dreading not receiving it; wishing for adulation amidst the worry that it is undeserved” (Hoffman, 2018, p. 7).

According to various psychodynamic research interviews (McEvoy, O’Connor, & McCarthy, 2016), one of the main developmental struggles for people suffering from SAD seems to be reaching an authentic self – an own identity which has its own opinions, aware of its needs and wishes and is able to give voice to them in interaction with others.

Most people with social anxiety wish for nothing more than to be accepted, noticed and admired by others.

When this desire is very intense and the person is convinced of not being worthy of love and approval, an inner conflict may arise.

The result can be intense emotional reactions in situations of possible social evaluation.

However, this conflict and the underlying wishes and convictions may be unconscious.

Psychodynamic psychotherapy aims to gain clarity over these aspects and provide new ways of positioning the self in relation to others.

Among the main differences in comparison to other approaches is the focus on early childhood experiences, especially the relationship to parents and early childhood caregivers, and how these affect the patient’s experiences in the present.

The most famous version of psychodynamic psychotherapy is traditional psychoanalysis, originally developed by Sigmund Freud.

However, you are not restricted to this option. Several treatment modalities fall into this category.

For example, brief psychodynamic therapy enables the patient to unravel and work on unconscious conflicts in a timely manner.

The science on the effectiveness of psychodynamic therapy for social anxiety disorder is strong, especially on the long run (Bögels, Wijts, Oort, & Sallaerts, 2014; Leichsenring et al., 2014).

Depending on your therapist, the duration of the intervention may vary widely. While brief interventions may only take 12 sessions, more thorough treatments can take up to several years with various sessions a week.

Interpersonal Therapy

Influenced by CBT and psychodynamic theories, interpersonal therapy focuses on the patient’s inadequate behaviors in their relationships.

To identify problematic patterns in the patient’s way of relating to others, the following questions may be examined (Lipsitz, 2012):

1. How close and intimate does the patient want to be with others? How do they reveal this to them?
2. How much in charge does the person want to be in relation to others? Do they tend to seek control or prefer to give it up to others? How do they communicate this?
3. To what degree does the patient want to let others play a significant part in their life? How do they let them know?

Most of the times, this communication happens on a nonverbal level.

The therapeutic relationship provides an ideal space for these patterns to emerge, to be identified, and to be changed.

Interpersonal therapy has an average duration of about 12 – 16 sessions. Again, this may vary depending on the therapist and institution.

The science on its effectiveness for social anxiety disorder is still scarce. However, preliminary findings are promising, reporting good efficacy for socially anxious people (Borge, Hoffart, Sexton, Clark, Markowitz, & McManus, 2008; Markowitz & Lipsitz, 2014).

Mindfulness & Meditation

The mindfulness wave of the last decade has led to significant adjustments in the treatment of social anxiety.

New approaches have been emerging, which take a very different approach.

While traditional CBT emphasizes the adjustment of maladaptive negative thoughts, acceptance-based approaches advocate mindfulness.

Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally”, by Jon-Kabat-Zinn (1994) from the University of Massachusetts Medical School.

Socially anxious people usually try to suppress their anxiety or physical symptoms, which tends to intensify them.

Mindfulness teaches to observe and notice what is happening without the intention to alter the experience in any way.

Mindfulness reduces our natural tendency to fight any unpleasant experiences. For this reason, it is a great intervention for socially anxious people.

Instead of challenging uncomfortable feelings and counterproductive thoughts, mindfulness-based approaches teach psychological acceptance of these phenomena.

Like this, it bypasses the ironic thoughts process – a psychological phenomenon which paradoxically intensifies a thought or sensation when the person actively tries to suppress it.

But this is not the only reason why mindfulness meditation is an effective intervention for social anxiety.

Regular meditation practice has been shown to affect brain activity, as the prefrontal cortex becomes thicker and gains more influence over the amygdala, also referred to as the fear center of the brain.

In stressful situations, the brain is then more likely to remain calm and not overreact.

In the case of social anxiety, the threat is often imagined or drastically amplified by the affected person.

Therefore, training the brain through meditation to maintain control in stressful situations is a great practice.

Several group programs have been developed and applied to people with SAD. Among the most popular ones are mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).

Numerous studies have reported good effectiveness for these interventions applied to SAD (Bögels, Sijbers, & Voncken, 2006; Koszycki, Benger, Shlik, & Bradwejn, 2007; Piet, Hougaard, Hecksher, & Rosenberg, 2010).

These programs usually last 10 – 12 weeks and lead to substantial reductions in social anxiety.

Compassion-Based Treatment

Another new treatment for social anxiety is based on compassion.

Compassion refers to a “sympathetic consciousness of others’ distress together with a desire to alleviate it” (Merriam-Webster, 2020).

Compassion-focused therapy is based on the idea that humans evolved having three different basic motivational-emotional systems (Gilbert, 2014).

1. The Threat System
2. The Competition System
3. Affiliative System

While the threat and competition systems tend to activate and arouse us, the affiliative system has soothing qualities and puts us in a prosocial state.

When this latter system is activated, our brain works and organizes its activity in a way which promotes mental health and significantly lowers anxiety.

Compassion-focused therapy aims to train people’s ability to cultivate affiliative emotions related to others and towards themselves.

Reacting with self-kindness and self-compassion when faced with personal flaws or failures has been shown to have an anxiety-buffering effect (Werner et al., 2012).

However, socially anxious people tend to miss out on this mental health benefit.

They usually have low levels of self-compassion and tend to critizie themselves when faced with personal failures.

In fact, people with social anxiety disorder represent a group with particularly high levels of self-criticism (Cox, Fleet, & Stein, 2004).

A further therapy for social anxiety which is based on the way we relate to ourselves is mindful self-compassion (Neff, 2003).

As the name suggests, it focuses on becoming aware of our own suffering and reacting with compassion and kindness when we have to endure difficult moments.

Socially anxious people have a strong tendency to be harsh on themselves when it comes to their flaws, particularly their own social anxiety.

Mindful self-compassion advocates the idea that criticizing ourselves when we are down only amplifies the problem and our suffering.

Instead of putting ourselves down, it encourages people to react with compassion for themselves, as they would with a friend who is going through a difficult moment.

Harwood and Kocovski (2017) examined what happened when people high in social anxiety measures engaged in a self-compassion inducing exercise before a speech task.

Results showed clear benefits for these individuals and confirmed once again the anxiety-buffering effect of self-compassion.

Preliminary findings regarding the effectiveness of compassion-focused therapy have been positive, especially for those with high levels of self-criticism (Leaviss & Uttley, 2014).

The treatment duration for compassion-based approaches varies widely, ranging from 12 to 50 sessions.

Metacognitive Therapy

Remember how traditional CBT addresses negative thoughts?

Let’s say you are afraid of public speaking and you must give a speech. Before and during the event, automatic negative thoughts like the following may pop up in your mind.

• “I’m too nervous to do this.”
• “People in the audience will ridicule me.”
• “I can’t handle this anxiety.”

In traditional CBT, these thoughts are seen as the reason why people become socially anxious.

Thinking that you are not good enough, that others are judgmental, and that you will be anxious in future situations is believed to fuel your social anxiety.

However, there is another cognitive theory that has been proven to explain social anxiety quite well (Nordahl & Wells, 2017).

Metacognitive therapy emphasizes that beliefs about thinking itself are the main problem in people with SAD.

Socially anxious people often assume that certain thoughts are dangerous and that controlling them will therefore be beneficial.

However, their attempts to do so typically fail and lead to more anxiety, which confirms their assumption.

“I knew that these thoughts were dangerous, I knew I should have suppressed and avoided them.“

This phenomenon has been called cognitive-attentional syndrome (Wells, 2009). It refers to the monitoring of our mental processes.

By thinking about the way we think, we move up one level – from cognitions to metacognitions.

Our metacognitions lead to certain thinking styles (Wells, 2009). When these styles are maladaptive, social anxiety can be the result.

You may believe it is helpful to worry about what could go wrong in an upcoming social event so you can prevent it.

In the same way, you might think that ruminating about past social events can help you avoid certain behaviors or physical symptoms in the future.

These beliefs about thinking tend to increase the anxiety instead of reducing it.

For example, you may believe that it is beneficial to be highly alert when with others. Many people with SAD believe that this helps them detect potential social danger and avoid worst case scenarios.

So, they tend to focus on any signals of social threat or disapproval.

Their thinking style has become maladaptive and jeopardizes their social performance. This is where metacognitive therapy intervenes.

By questioning unhelpful beliefs about thinking and adjusting them accordingly, social anxiety can be reduced significantly. The science on its effectiveness has been convincing (Lakshmi, Sudhir, Sharma, & Math, 2016; Nordahl & Wells, 2018).

The average duration of treatment is 8-10 sessions. Metacognitive therapy for social anxiety is yet to be offered on a larger and global scale.

Medication for Social Anxiety Disorder

For a considerable part of socially anxious people, their anxiety is simply too immense to handle.

In these cases, pharmacotherapy can be a valid option.

It can provide short term relief, lead to results quite quickly, and make psychotherapy easier for affected people.

Research on the effects of medication for social anxiety has been ongoing ever since the condition was recognized by the APA in 1980.

While earlier trials focused on the anxiety-reducing effects of benzodiazepines, β-blockers and MAOIs, the attention of investigations has since then expanded to SSRIs, SNRIs and RIMAs and other, more novel, substances.

Here, we will have a closer look on the most commonly prescribed medications for social anxiety.

Whether or not you take medication can be a difficult choice. This decision should always be closely administered by a qualified professional and based on a thorough assessment of your individual case.

The evaluation must include screening for any co-occurring psychiatric and medical conditions (Schneier, Bragdon, Blanco, & Liebowitz, 2014). It is crucial to detect any relevant contraindications in order to avoid adverse treatment effects.

SSRIs & SNRIs

Selective serotonin reuptake inhibitors (SSRIs) were originally developed to treat depression.

They limit the reuptake of the neurotransmitter serotonin after it has been released into the synaptic cleft, a common process in the central nervous system.

Serotonin norepinephrine reuptake inhibitors (SNRIs) work in a similar fashion, but additionally to serotonin they inhibit the reabsorption of norepinephrine after its release into the synaptic cleft.

Just as SSRIs, SNRIs belong to the group of second-generation antidepressant medication.

In the mid-ninety’s, the first trials examining the effects of SSRIs and SNRIs in people with SAD were conducted.

Since then, their efficacy for social anxiety disorder has been continuously proven in numerous randomized controlled trials (RCTs) and side-effects are usually tolerable for most individuals (Schneier, Bragdon, Blanco, & Liebowitz, 2014).

Due to their antidepressive properties, they usually have positive effects on depression as well, which often comes along with SAD.

Therefore, SSRIs and SNRIs are considered first-choice medications for social anxiety disorder.

The most commonly prescribed SSRI and SNRI medications for social anxiety disorder are (Schneier, Bragdon, Blanco, & Liebowitz, 2014):

• Paroxetine
• Fluvoxamine
• Sertraline
• Escitalopram and citalopram
• Fluoxetine
• Venlafaxine

All of the above medications have been shown to reduce social anxiety, with fluoxetine being the only substance that showed mixed results.

As it is common for antidepressants that their effects usually manifest after about four weeks of treatment, its anxiety-reducing effects can and should be expected around the same time.

MAOIs & RIMAs

Monoamine Oxidase Inhibitors (MAOIs) constrain the enzyme monoamine oxidase, whose job it is to break down serotonin, dopamine and norepinephrine.

Since MAOIs block this enzyme, the neurotransmitters are not broken down anymore, which increases their concentration in the brain.

This effect is not only of benefit for people with depression, but also for those suffering from social anxiety disorder.

Phenelzine and tranylcypromine, the most common MAOIs, have been proven effective as social anxiety treatments (Blanco et al., 2010; Gelernter et al., 1991; Heimberg et al., 1998; Liebowitz et al., 1992, Nardi et al., 2010; Versiani et al., 1992).

MAOIs tend to produce more side-effects than the previously discussed medications.

Additionally, they can lead to hypertensive crisis when too much norepinephrine is released. This may happen when consuming certain foods.

Reversible Inhibitors of Monoamine Oxidase A (RIMAs) also bind and inhibit monoamine oxidase A. However, opposed to MAOIs, they do so reversibly.

This means that some of the neurotransmitters previously mentioned are broken down after their release into the synaptic cleft.

This is especially important in the case of norepinephrine, since this drastically decreases the chances of hypertensive crisis.

Be that as it may, their reversibility comes along with lower efficacy in the treatment of social anxiety (Schneier, Bragdon, Blanco, & Liebowitz, 2014).

The only marketed RIMA is moclobemide. Brofaromine, another one, has led to good results in three RCTs, but has not been marketed.

Benzodiazepines

Benzodiazepines, often referred to as “benzos”, form part of the drug family of minor tranquilizers and are among the most commonly prescribed medications for anxiety.

There are several studies that support their efficacy in reducing social anxiety symptoms (Davidson et al., 1993; Munjack, Baltazar, Bohn, Cabe, & Appleton, 1990; Ontiveros, 2008; Versiani, Amrein, & Montgomery, 1997).

Clonazepam and bromazepam, but not aplrazolam (Gelernter et al., 1991), were considered effective medications for social anxiety based on the double-blind studies conducted.

Side-effects can be severe, including impaired cognition, high risk of falling, withdrawal effects, and especially abuse and dependency (Schneier, Bragdon, Blanco, & Liebowitz, 2014).

For this reason, the use of benzodiazepines for social anxiety should not be long-term and is rather used on an as-needed basis for public speaking and performance anxiety.

Also, as with all medications, close administration by a qualified professional is crucial to avoid adverse treatment effects.

β-Blockers

β-adrenergic antagonists, also called beta-blockers, block certain receptor sites in the nervous system which usually interact with the neurotransmitters epinephrine and norepinephrine.

When epinephrine binds to a receptor site, it stimulates a stress response.

Beta-blockers inhibit this process by blocking the receptor sites and therefore reduce the body’s stress response.

When taken before a feared performance situation, such as public speaking, β-blockers are effective in decreasing the anxiety response of the automatic nervous system (Hartley, Ungapen, Davie, & Spencer, 1983; Neftel et al., 1982).

However, when taken on a daily basis by people with generalized SAD (anxiety in most social situations), this type of medication does not produce any benefits (Liebowitz et al., 1992, Turner, Beidel, & Jacob, 1994).

Therefore, for those with SAD, the use of beta-blockers seems restricted to people who suffer from performance or public speaking anxiety on an as-needed basis (Schneier, Bragdon, Blanco, & Liebowitz, 2014).

CBD

Cannabidiol, a cannabinoid also known as CBD, has been subject to many scientific investigations throughout the last decade and represents a novel, promising medication for social anxiety.

It has been reported that CBD has an impact on the activation of certain brain areas, specifically in lymbic and paralymbic regions (Crippa et al., 2011).

These changes in brain activity are linked to reduced anxiety in people with SAD.

Since CBD is a nonaddictive component of the Cannabis sativa plant and has nonpsychotomimetic properties, it may become more commonplace as a treatment for social anxiety in the near future.

Several trials have shown promising results, confirming the anxiety-reducing effects of CBD in people with SAD and avoidant personality disorder (e.g., Bergamaschi, Querioz, Chagas, Oliverira, & Martinis, 2011; Crippa et al., 2011; Masataka, 2019).

Whether or not to take medication is a personal choice, which should always be properly discussed with your physician.

While some people find medication helpful and report positive experiences, others do not experience the expected relief and struggle with their side-effects.

Next up, we will cover some practical things you can do to reduce your social fears.

Practical Tips for Social Anxiety Disorder

The literature discussed above refers to the official treatments for social anxiety and requires reaching out for professional help.

However, there are various practical interventions that can help you reduce your social anxiety on your own.

In this section, we will discuss numerous tips for social anxiety that usually provide some relief for most affected people.

Sleep

By now, there is a large body of evidence indicating that sleep deprivation not only takes a toll on our physical, but also our mental health.

Sleep loss has been consistently associated with emotional irritability, aggression and anxiety (e.g., Anderson & Platten, 2011; Horne, 1985; Dinges et al., 1997; Zohar, Tzischinsky, Epstein, & Lavie, 2005; Minkel, et al., 2012).

In other words, our emotional reactivity is significantly impacted by the duration and quality of sleep we get.

For people with SAD, this means that getting enough shut eye and prioritizing good sleep should form part of the basics.

If you suffer from sleep disruptions, it is important to follow some basic rules in order to get good, sufficient rest.

Among the most important rules of thumb experts recommend are the following:

• no caffeine after lunchtime
• don’t use alcohol to fall asleep
• regular physical activity
• create a personal ritual before going to bed (like reading, meditating, use certain scents, etc.)
• only go to bed when tired
• don’t watch TV or read in your bed (you want your brain to associate this place with sleep, not with being awake)
• get up around the same time everyday
• no naps during daytime if you have trouble sleeping at night

Keep in mind that sleep cannot be forced. Instead of attempting to sleep, simply try to relax. Your mind and body recover when you lay down, shut your eyes, breathe slowly and keep calm.

Physical Exercise

Like sleep, physical exercise has an important impact on health. This is true for our physical, but also our mental well-being.

Research regarding the mental health benefits of regular physical activity has been piling up over the last decades.

There have even been some trials that specifically included people with SAD in order to see if exercise is an effective supplementary intervention for this population.

For example, one study investigated whether adding physical activity to a traditional group CBT treatment for social anxiety would be more effective compared to the CBT intervention by itself (Merom et al., 2008).

While patients with generalized anxiety disorder and panic disorder did not benefit from the exercise induction, those with SAD averaged significant improvements on measures for anxiety, depression, and stress.

The study participants were instructed to engage in simple walking on five days a week for a total of 150 minutes. The intervention lasted 10 weeks.

The positive effects of physical exercise on social anxiety could be replicated by other research teams, suggesting that it is an effective intervention (Jazaieri, Goldin, Werner, Ziv, & Gross, 2012; Jazaieri, Lee, Goldin, & Gross, 2016; LeBouthillier and Asmundson, 2017).

This was found to be true for aerobic exercise, such as running or swimming, and for anaerobic activities, such as resistance training.

As exercise provides a wide range of health benefits, not only related to anxiety, becoming more physically active represents a desirable lifestyle change for most people with SAD.

A recent systematic review and meta-analysis of numerous studies examining the effects of exercise on anxiety concluded that high intensity exercise regimens are more effective in reducing anxiety symptoms than low intensity training (Aylett, Small, & Bower 2018).

Additionally, the anxiety-reducing effects of exercise could be maintained several month after completing the intervention.

Make sure to always consult with your physician before starting a new workout routine.

Breathing Techniques

Breathing is not only crucial to our immediate survival, but the way we engage in it has an important impact on physiological, and therefore psychological, processes in our body.

When carried out in a particular way, breathing has been shown to increase parasympathetic activity, which slows down the heart rate (Zaccaro et al., 2018).

Additionally, slow breathing exercises have the potential to alter brain activity in a way which promotes emotional control and have been linked to greater well-being.

When faced with a stressful event, such as a feared social situation, the brain triggers the release of cortisol. Cortisol is a stress hormone which helps the body handle difficult situations.

In the case of social anxiety, cortisol is released in social situations which pose no real threat, and therefore has a counterproductive effect.

Slow breathing practice has been suggested to normalize the body’s stress response (Lehrer et al., 2010) and deep breathing is associated with sustained attention, positive emotion, and lower cortisol levels (Ma et al., 2017).

Different types of breathing techniques have proven beneficial to psychological well-being, due to emotion enhancement and reduction of anxiety, depression and stress (Brown and Gerbarg, 2005a,b; Anju et al., 2015; Stromberg, Russel, & Carlson, 2015).

Diaphragmatic breathing, also known as “deep breathing“, is a broad term which encapsulates various types of breathing techniques with origins in yoga, meditation, and psychotherapy.

Treatment for social anxiety often includes some of them.

Deep breathing may be practiced regularly or on an as-needed basis before, during, and after a feared social situation.

However, for inexperienced newcomers, it is important to follow some basic guidelines to avoid adverse effects.

It is not recommended to engage in rapid, consecutive inhalations, as this increases the risk of hyperventilation and activates the sympathetic nervous system, which rather amplifies anxiety.

While breath holding for short periods of time is often recommended and can help reduce anxiety, it may also lead to negative effects if the air is retained for too long (Krishnananda, 2009).

Exercises which include long breath holding should therefore be practiced with a qualified professional.

There are many different deep breathing exercises that can help reduce anxiety in social situations.

One of them is the so-called box-breathing technique, which is especially helpful to help people manage stressful situations (Norelli, Long, & Krepps, 2020).

Unlike its name may suggest, this exercise does not instruct to breath into a box. Instead, you imagine a box with 4 equal parts, with each of them representing one of its steps.

It can be practiced before, during, or after a feared social situation and does not require a tranquil, stress free environment in order to work.

1. Inhale through the nose (4 seconds)
2. Hold breath (4 seconds)
3. Exhale through mouth or nose (4 seconds)
4. Hold breath (4 seconds)

This process is then repeated as needed and as it feels comfortable.

You can adjust the length of the individual steps to your needs and preferences. For example, if you feel more comfortable with a count of three or six in each step, simply adjust the exercise.

Exposure

If you suffer from social anxiety, you are probably familiar with the tendency to avoid feared social situations.

There is a general consensus among experts that avoidance maintains social anxiety. This means that the vicious cycle of avoidance needs to be broken if you want to overcome your social fears.

There are many brave people who face their fears in order to do so. However, most of the time they engage in some form of safety behavior when doing so.

These safety behaviors can be applied consciously or unconsciously. People with SAD do so to avoid worst case scenarios and negative outcomes in stressful social situations.

A typical safety behavior of people afraid of seeming weird and reserved is to check their phone when they are in a group.

They might do so to not seem shy and introverted, or not having to engage in conversation.

Applying these safety behaviors is another form of avoidance. By engaging in them, exposure to the feared stimulus is restricted.

By pretending to be chatting on the phone, they are not exposing themselves to the situation they really fear.

In this case, this could be being in a small group of people who are engaging in conversation.

Exposure to the feared situations is very effective in reducing social anxiety symptoms (Turner, Beidel, & Jacob, 1994; Alström, Nordlund, Persson, Hårding, & Ljungqvist, 1984).

In fact, it can be seen as one of the most powerul tools when it comes to social anxiety treatment. It usually forms part of any successful intervention in one way or another.

Looking for opportunities in everyday life to face situations you have been avoiding due to fear of disapproval is certainly a huge step into the right direction.

This process can be gradual as it can be quite challenging. However, if you are persistent in this pursuit, you are on the right track.

Wrapping up: If you start improving your sleep habits, to work out sufficiently, start using your breathing to your advantage and begin to face your fears step by step, you are off to a good start.

If you are interested in more practical tips for SAD, check out our actionable intel for social anxiety disorder.

Finding the Right Therapist & Treatment Modality

By now, you should have a basic understanding of the effective interventions for social anxiety.

You have learned about the different psychotherapies, about possible medications, and you are equipped with some basic tips for social anxiety.

In this section, you will learn how to initiate treatment.

Who do you turn to? Who accounts for the treatment costs? What is better for you, individual or group therapy? Is online treatment a valid option?

Let’s get answers!

Getting Started

Before you set out to initiate treatment, you may want to consider a couple of important questions. Your answers to these questions will help you find the right therapist and treatment modality.

• Do you have any preferences regarding the type of psychotherapy you will receive? You may resonate more with one approach than with another.
• Do you prefer a brief therapy which focuses on the main problem and symptom reduction, or do you prefer to dig deep and explore the underlying causes of your problem? The former can often provide quicker relief, the latter can lead to more profound changes on the long run.
• Do you have health insurance which covers psychotherapy? If you do, you may want to speak to your primary physician and get a prescription for psychotherapy. If you do not: How much can you afford to spend and how much are you willing to spend for your treatment?
• What is your preferred treatment modality and method of delivery? You may prefer individual or group therapy, or you live in a rural area and are inclined to try online therapy.

Pros & Cons of Group Therapy

Group therapy for social anxiety usually consists of one or two therapists and 6-12 participants with SAD.

Most of these interventions are based on CBT. However, mindfulness-based group programs have been increasingly offered throughout the last years.

Pros	Cons
Meet people who share similar problems.	Very shy & anxious people may participate less.
Members can provide reciprocal support.	Relationship to therapist may be weaker.
For some, sharing experiences can be easier.	For others, sharing experiences can be harder.
Solving others’ issues can help with own problems.	Members may benefit from distinct interventions.
Can improve social skills.	Risk of lower confidentiality.
Regular exposure to group scenarios.	Social anxiety issues can be very diverse.
Usually more affordable.	Less attention on own issues.
Breaks cycle of social isolation.	More difficult to fit to own schedule.

Pros & Cons of Individual Therapy

Individual therapy typically refers to one-on-one sessions with a therapist. Psychotherapy should only be provided by therapists who have been professionally trained.

As the American Psychiatric Association points out, the following professionals can provide psychotherapy:

• Psychiatrists
• Psychologists
• Licensed Social Workers
• Licensed Professional Counselors
• Licensed Marriage & Family Therapists
• Psychiatric Nurses
• Others With Specialized Training In Psychotherapy

Pros	Cons
Full attention from therapist.	For some, it can be too much, too fast.
Fully focused on personal problems.	Some fear being sole center of attention.
For many, sharing experiences can be easier.	For some, sharing experiences can be harder.
Stronger therapeutic alliance.	No social support from others with same issues.
Complete confidentiality.	Usually more expensive.
Appointments & pace adjusted to client.	There are only two viewpoints, not many.
Many therapists offer emergency sessions.	A particular therapist can be a bad fit for client.

In-Person Treatment

Usually, psychotherapy is administered in-person, meaning therapist and patient meet face-to-face.

Not only do real-life encounters between you and your therapist get you out of your house and socialize with another person, but there are other important benefits to consider.

From the therapist’s point of view, being able to pick up on the patient’s body language, such as posture and gestures, adds additional value to the treatment process.

Considering the patient’s perspective, sensing the physical, recurrent presence of a significant other who cares and can be trusted is often therapeutic in and of itself.

While this can certainly happen through online therapy, in-person treatment provides the ideal conditions for meaningful therapeutic alliances to emerge.

In the case of social anxiety disorder, the affected person has often been keeping social encounters to a minimum. Regular meetings with a non-judgmental, accepting other can break this cycle of social isolation.

Establishing a deep and meaningful connection with the therapist despite (and usually because of) opening up about personal shortcomings and presenting social anxiety symptoms is often a key factor in treatment for SAD. In-person treatment provides the ideal environment for this experience.

Online Treatment

Considering the defining features of social anxiety disorder, namely the fear of being judged, negatively evaluated, or humiliated by others, online therapy is often the preferred mode of treatment delivery for affected people.

As we mentioned in the intro of this guide, four out of five people with SAD never receive professional help. One of the reasons is the fear of being judged by their therapist.

For example, the thought of displaying physical signs of anxiety during therapy can paralyze socially anxious people. They may dread being judged or looked down on by their therapist, which gets in the way of reaching out for support.

Other people may want to access in-person treatment, but have no physical access to treatment facilities. This is often the case in rural areas without mental health care professionals familiar with social phobia.

Another important factor are the costs of therapy. Depending on your country of residence and your health insurance, you may have to pay for the treatment yourself.

While psychotherapy is quite often a costly endeavor, online therapy is usually considerably cheaper than in-person treatment.

Not only does the patient save on costs for transportation, but the option of receiving pre-recorded sessions as part of an online therapy program can reduce the price of treatment significantly.

In this case, the patient gets access to a structured treatment program for social anxiety, which includes education about the disorder, specific interventions as well as homework assignments.

This way, one-on-one sessions are only administered if specific questions or unique issues come up, which decreases the price of therapy significantly.

In terms of effectiveness, online therapy has produced impressive results for somatic and psychiatric disorders, with research indicating equivalent effect sizes for online therapy and in-person treatment (Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014).

This is also the case for social anxiety disorder, which can be reduced significantly through online interventions (Hedman, Andersson, Ljótsson, Andersson, Rück, Mörtberg, & Lindefors, 2011; Nordgreen, Gjestad, Andersson, Carlbring, & Havikb, 2018; Tulbure, Szentagotai, David, Ștefan, Månsson, David, & Andersson, 2015).

Locating Suitable Facilities & Therapists

Once you have identified your preferred type of psychotherapy, have clarity over the financial aspects of treatment, and have decided whether to go for individual or group therapy, it is time to search for potential therapists and institutions.

To do so, you may want to make a list of psychiatric, psychosomatic, and psychotherapeutic facilities in your area.

Then you can head over to their websites and identify what type of psychotherapy they offer.

To find individual therapists who run their own practice , you can use the Psychologist Locator (APA) and the Find A Therapist Tool (ADAA).

If you do not live in the United States, you may be able to find a similar search tool for your country.

We recommend making a list of several options. Sometimes, therapists and institutions are fully occupied and can therefore decline your request. So, it is good to have a plan b and c.

Participate in a Research Study!

If you are affected by social anxiety, you can help researchers and clinicians better understand the condition and improve treatment efficacy by participating in a research study.

To take part, you can click here to open a short, quick survey in a new browser window, or simply fill out the form provided below. Thank you for your participation!

Also, if you suffer from social anxiety and are looking for ways to get better, feel free to sign up for our community newsletter.

By subscribing, you’ll receive valuable information about the condition, its treatment options, and practical advice on how to cope.

Community members are kept up to date on the latest scientific findings, informed about new releases (e.g. our upcoming online course) and receive special discounts.

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